Experts Urge Global Fund for AIDS, TB and Malaria: “Buy More Health for the Money”

The Global Fund to Fight AIDS, Tuberculosis and Malaria disburses more than a billion dollars a year and has likely saved millions of lives-but it could save many more lives and avert untold suffering by re-structuring its activities to get more health for the money, according to a new report from the Center for Global Development (CGD).

“The Global Fund could save many more lives if they are willing to change how they do business to focus more on results and less on receipts,” says Amanda Glassman, director of global health policy at the Center for Global Development and the lead author of the new working group report.

“Getting more value for the money is not merely a checklist, a principle or another task on the to-do list-it is the core business of any health funder. Our report explains how the Global Fund can do that,” Glassman adds.

Foreign assistance for health has reached historic highs in recent years, largely due to the growth of the Global Fund. From 2002 to 2011, the Global Fund disbursed $15.5 billion to support more than 1,000 programs in over 150 countries. This year the United States alone pledged over $1.6 billion to the Global Fund, more than it gave to the World Bank, the regional development banks, and other multilateral channels combined.

But with tight budgets and sluggish economic growth in the high-income economies, continued rapid increases in global health assistance are considered unlikely, so attention is turning to getting the most from the money already on the table.

Mark Dybul, head of the Global Fund and the former director of the US anti-AIDS program, PEPFAR, wrote in a recent Global Fund blog post: “We must make our money count. Great investments are effective and efficient. In order to raise the money we need for global health we need to demonstrate to everyone that this money is put to excellent use.”

According to More Health for the Money, the Global Fund has plenty of room for improvement:

The Global Fund subsidizes the purchase of a wide variety of mosquito nets-with some costing up to several times more than others-without clear evidence to show which if any of the more expensive brands are worth the extra money.

In more than a dozen countries in Africa, the Global Fund pays about $50 to supply a patient with a year’s worth of a widely used anti-AIDS drug. But in Iran, Albania and the West Bank and Gaza, it pays more than $1,000 for the same amount of the same drug.

Global Fund AIDS prevention money is often spent on raising general awareness rather than providing people most at risk with the means to avoid infection. In Costa Rica an estimated 60 percent of AIDS cases occur among men who have sex with men, but just 1% of the country’s spending on prevention is targeted to this high-risk group.

First-line medications are much more cost effective than the second- and third-line medicines given when first-line medications fail. Nonetheless, the Global Fund subsidizes second- and third-line medications in several low-income countries even though many people there are dying for lack of first-line medicines.

Members of the working group that prepared the report include experts from a wide range of disciplines, countries and organizations. They concur that by focusing on outcomes and strengthening incentives, the Global Fund, its partners, and other global health donors can correct these and other problems.

“The changes we recommend, while seemingly small and bureaucratic, can make a revolutionary difference for the Global Fund,” says working group member Yot Teerawattananon, the director and senior researcher at the Health Intervention and Technology Assessment Program in Thailand. “Focusing on results-based interventions, cost effectiveness, and performance metrics will be an important step towards ensuring that the billions of dollars spent by the Global Fund are getting the greatest value for money.”

Working group member Karl Dehne, a UNAIDS official, says that with the new funding pledges “the Global Fund has the capacity to make a significant, measurable impact on the global health landscape - but only if administrators keep their eye on preserving value for money. This report presents ways to ensure that all the additional resources get the largest possible bang for the buck.”

“The work of the Global Fund has been admirable - but it can do much better,” says CGD president Nancy Birdsall. “The changes the report recommends are not easy in any bureaucracy. But the Global Fund has been a pioneer since its inception, and many of the ideas in this report are already on the agenda of the Fund’s new leadership, its own funders, and the global health advocates that have been the bedrock of its support and effectiveness. I am optimistic.”

The report offers a four-part strategy to get more value for money. While each step corresponds to a different part of the Global Fund’s grant making process, the issues and sequence are common to all funders-as are the suggested solutions:

Allocation: The Global Fund has relied upon a passive approach to grant allocation, responding to country requests. Lacking clear budget constraints, and rewards for efficiency, or predictable funding opportunities, countries maximize their funding requests, leading to inefficiencies and overspending. Moving forward, the report recommends that the Global Fund create a menu of effective and cost-effective options from which countries could select what they need. Menu options should include activities that focus prevention and treatment on people at greatest risk from the diseases.

Contracts: As contracts are currently designed there are few incentives for demonstrating program impact and few penalties for failing to do so.

Moving forward, the experts in the working group urge the Global Fund to align funding with incentives for effective action. Linking funding to outcomes within contracts will encourage recipients to meet goals rather than merely implement programs. For example, with proper monitoring and testing, a contract could pay for a reduction in the number of new HIV infections, rather than for inputs such as condoms or counseling.

Cost and spending: The missing piece in most contracts and programs administered by the Global Fund is the unit cost of services delivered - such as the cost of successfully treating one person with tuberculosis-an elusive but critical piece of information.

Moving forward, the experts suggest the Global Fund track this information and, whenever possible, write the information into contracts. The agency can also share and publicize the information with partners and the public to reduce costs.

Performance and verification: The adage suggests that what gets measured gets done - and current measurement tools employed by the Global Fund are weak and inaccurate.

Moving forward, experts advise the Global Fund to identify new, more rigorous tools to measure impact and hire an independent third party to verify the accuracy and quality of results. This way, the Global Fund and international health donors can be sure that their funding was used to produce positive health results.

CGD president Nancy Birdsall adds:

“This report has practical ideas for all funders of global health programs, indeed for all outside funders of social services in developing countries, of how to incorporate into their business practices sensible incentives - for themselves and for grantee countries - to minimize costs and maximize results on the ground.”

Working Group Chair and report author Amanda Glassman, who is also a CGD senior fellow, adds:

“Value for money is not about reducing costs or cutting budgets, but rather about maximizing the health impact of every available peso, pound, or pula to reduce human suffering and save lives.”

A companion website, www.MoreHealthfortheMoney.org offers a quick and interactive way to read and share the report’s findings. The site features a short video and digital briefs that highlight key messages and recommendations from the report, many illustrated by expert commentary and interactive graphics.